Sexual Behavior,Risk Compensation,and HIV Prevention Strategies Among Participants in the San Francisco PrEP Demonstration Project: A Qualitative Analysis of Counseling Notes

Pre-exposure prophylaxis (PrEP) is a viable HIV prevention strategy but risk compensation could undermine potential benefits. There are limited data that examine this phenomenon outside of clinical trials. We conducted a qualitative analysis of counseling notes from the San Francisco site of the US PrEP demonstration project to assess how men who have sex with men used PrEP as a prevention strategy and its impact on their sexual practices. Four major themes emerged from our analysis of 130 distinct notes associated with 26 participants. Prevention strategy decision-making was dynamic, often influenced by the context and perceived risk of a sexual encounter. Counselors noted that participants used PrEP in conjunction with other health promotion strategies like condoms, asking about HIV status of their sex partners, and seroadaptation. With few exceptions, existing risk reduction strategies were not abandoned upon initiation of PrEP. Risk-taking behavior was ‘seasonal’ and fluctuations were influenced by various personal, psychosocial, and health-related factors. PrEP also helped relieve anxiety regarding sex and HIV, particularly among serodiscordant partners. Understanding sexual decision-making and how PrEP is incorporated into existing prevention strategies can help inform future PrEP implementation efforts.     

A Network-Individual-Resource Model for HIV Prevention

HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual’s relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual’s current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.     

Community perceptions of the socio-economic structural context influencing HIV and TB risk,prevention and treatment in a high prevalence area in the era of antiretroviral therapy

Following calls for targeted HIV prevention interventions in so-called “hotspots”, we explored subjective perceptions of community members in places considered to be high HIV and tuberculosis (TB) transmission areas and those with low prevalence. Although more people now have access to antiretroviral therapy (ART), some areas are still experiencing high HIV transmission rates, presenting a barrier to the elimination of HIV. A rapid qualitative assessment approach was used to access a sample of 230 people who contributed narratives of their experiences and perceptions of transmission, treatment and prevention of HIV and TB in their communities. Theoretical propositions case study strategy was used to inform and guide the thematic analysis of the data with Research Department of Epidemiology & Public Health, University College London, London, UK. Our results support the concept of linking perceived control to health through the identification of structural factors that increase communities’ sense of agency. People in these communities did not feel they had the efficacy to effect change in their milieu. The few socio-economic opportunities promote social mobility in search of better prospects which may have a negative impact on community cohesion and prevention strategies. Communities were more concerned with improving their immediate social and economic situations and prioritised this above the prevention messages. Therefore approaches that focus on changing the structural and environmental barriers to prevention may increase people’s perceived control. Multifaceted strategies that address the identified constructs of perceived control may influence the social change necessary to make structural interventions successful.     

Reducing social vulnerability to HIV/AIDS: models of care and their impact in resource-poor settings

There has been an increasing understanding of the social, economic, cultural and political factors that have shaped the HIV/AIDS epidemic. It has been widely recognized that in order to have effective prevention programmes for HIV/AIDS, the broader determinants of health must be addressed. Concurrently, a deeper understanding of personal and societal vulnerability to HIV/AIDS has emerged. Some prevention efforts have expanded their focus, addressing not only individual risk factors and behaviour, but also social justice and including community mobilization activities to address the wider context of the disease. However, the transition to an expanded approach to mitigating the effects of the HIV/AIDS epidemic has not been complete. There is little evidence that care and support strategies have systematically tried to address these concepts. While the role care plays in prevention is considered vital, viewing models of care in terms of their impact on the social vulnerability of certain groups to HIV/AIDS has been largely neglected. Yet appropriate care programmes that help reduce vulnerability will arguably also make the greatest contribution for prevention. Drawing on examples of the role social vulnerability has played in prevention efforts, this paper evaluates the impact of HIV/AIDS care models on socially vulnerable groups, such as women and children.     

Combination HIV prevention options for young women in Africa

Although the number of new HIV infections has declined by over 30% in the past decade, the number of people who acquire HIV each year remains unacceptably high. In 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that there were about 2 million new HIV infections. The virus continues to spread, particularly in key populations, such as men who have sex with men (MSM), transgender individuals, sex workers and people who inject drugs. In Africa, young women have the highest HIV incidence rates. Scaling up known efficacious HIV prevention strategies for these groups at high risk is therefore a high priority. HIV prevention has generally been targeted at HIV-negative individuals or in some instances, entire communities. Prevention efforts are, however, shifting from a narrow focus on HIV-uninfected persons to a continuum of prevention that includes both HIV-negative and HIV-positive individuals. Given that a single HIV prevention intervention is unlikely to be able to alter the epidemic trajectory as HIV epidemics in communities are complex and comprise a mosaic of different risk factors and different routes of transmission, there is need to provide combination prevention. Hence, a mix of behavioural, biomedical and structural HIV prevention options is likely to be needed to alter the course of the HIV epidemic. The combination of HIV prevention interventions needed will vary depending on cultural context, the population targeted and the stage of the epidemic. This paper reviews the available HIV prevention strategies for young women and discusses new HIV prevention approaches in development.     

Secondary HIV prevention

Primary HIV prevention, preventing HIV exposure among uninfected persons, has been the focus of much attention. However, secondary HIV prevention, preventing HIV transmission from infected people to their uninfected contacts, has not received as much interest or attention from HIV researchers, clinicians, and policymakers. The concept of secondary HIV prevention, as distinguished from primary prevention, is clarified, and the current and future strategies to further secondary HIV prevention efforts are explored. Secondary prevention strategies can be incorporated into comprehensive programs and result in shifts in attitudes and behaviors. This could reduce the size of the epidemic, while also benefiting the individual and his or her close relationships.     

The relevance of the content of an HIV and AIDS social intervention programme for the youth in the Northern Cape,South Africa

The numbers of people infected with HIV and living with AIDS remain high in South Africa. The youth of the Northern Cape province in South Africa are a vulnerable population in this regard. However, there seems to be a dearth of rigorous evaluations of HIV and AIDS social intervention programmes targeted at the youth. This study aimed to evaluate the relevance of the content of an HIV and AIDS social intervention programme for the youth in the Northern Cape as well as to collect attendees’ recommendations with regards to programme content. The data collection method comprised a group-administered questionnaire completed by youth (N = 172) who participated in the Soul City social intervention programme (SCP) implemented for the youth in the Northern Cape, and recruited through stratified random sampling. Based on specific criteria, the results showed that the SCP programme’s content was relevant to the communities it served. The youth also forwarded recommendations for the programme content. Recommendations from the study include that youth support should be beyond dialogues; women’s rights should be promoted within the context of HIV prevention strategies; the SCP should intensify its condom promotion efforts because it is relevant to the South African government’s macro-level plan; relevant community leaders should be visited to explain the rationale for the youth’s involvement in programmes; and the programme should focus more pertinently on poverty alleviation strategies.     

Building capacity to address gender and gender-based violence in HIV prevention in Mozambique

ABSTRACT

This article analyzes strategies that address gender inequality and gender-based violence (GBV) as part of HIV prevention efforts in Mozambique and describes the institutional support needed to implement these strategies. The analysis begins with a scan of the literature on pivotal HIV and GBV strategies. It then describes the context of the high prevalence of HIV and GBV in Mozambique, where civil society organizations (CSOs) involved in disease prevention and social services are limited in their organizational resources. An analysis of the experiences of six HIV prevention CSOs in Mozambique receiving capacity building inputs from FHI 360’s Capable Partners Program (CAP) from 2006 to 2015 to combat the twin epidemics leads to findings and conclusions relevant for literature and practice. Our findings indicate that community-level changes in attitudes regarding gender norms and organizational-level changes in the integration of gender and GBV are possible through a combination of interventions: provision of technical support, development of organizational capacity, and engagement of communities.     

Venues for Meeting Sex Partners and Partner HIV Risk Characteristics: HIV Prevention Trials Network (HPTN064) Women’s HIV Seroincidence Study (ISIS)

Identifying venues where women meet sexual partners, particular partners who increase women’s risk of acquiring HIV, could inform prevention efforts. We categorized venues where women enrolled in HPTN 064 reported meeting their last three sex partners as: (1) Formal, (2) Public, (3) Private, and (4) Virtual spaces. We used multinomial logistic regression to assess the association between these venues and women’s individual characteristics and reports of their partners’ HIV risk characteristics. The 2099 women reported meeting 3991 partners, 51 % at Public, 30 % Private, 17 % Formal and 3 % at Virtual venues. Women meeting partners at Formal venues reported more education and condom use than women meeting partners at other venues. Fewer partners met through Formal venues had “high” risk characteristics for HIV than through other venues and hence may pose less risk of HIV transmission. HIV prevention interventions can help women choose partners with fewer risk characteristics across all venue types.     

HIV Risk and Prevention Among Men Who Have Sex with Men (MSM) in Peri-Urban Townships in Cape Town,South Africa

Current guidelines on HIV prevention for MSM emphasise the need for ‘combination prevention’ based on context-specific understandings of HIV risk. MSM in South Africa are a population with a high risk of HIV infection, however there is little research available on the drivers of this risk. In the context of a focus on combination prevention, this paper argues that effective HIV prevention for MSM in South Africa requires an understanding of the factors at multiple ‘distances’ from individuals that contribute to HIV risk. Based on qualitative research with MSM in Cape Town, South Africa, we situate HIV risk using a socio-ecological framework and identify factors at distal, proximal, and personal, levels that contribute to MSM’s high risk of HIV infection. By understanding the interactions and linkages between risk environments and the risk situations in which HIV is transmitted, HIV prevention programmes will be more effectively able to address the multiple drivers of HIV risk in this population.     

Preventing HIV among Latino and African American gay and bisexual men in a context of HIV-related stigma, discrimination, and homophobia: perspectives of providers

HIV-related stigma, discrimination, and homophobia impede community-based efforts to combat HIV disease among Latino and African American gay and bisexual men. This commentary highlights ways to address these social biases in communities of color in Los Angeles, California, from the perspectives of staff from HIV prevention programs. Information was collected from HIV prevention program staff participating in a 2-day symposium. The outcomes from the symposium offer strategies for developing and implementing HIV prevention services for Latino and African American gay and bisexual men, which include: (1) addressing social biases present in a community that can hinder, and even prohibit, utilization of effective HIV prevention programs; (2) recasting HIV prevention messages in a broader social or health context; (3) developing culturally appropriate HIV prevention messages; (4) exploring new modalities and venues for delivering HIV prevention messages that are appropriate for gay and bisexual men of color and the communities in which they live; and (5) broadening the target of HIV prevention services to include service providers, local institutions and agencies, and the community at-large. These strategies underscore the need to consider the social and contextual factors of a community when designing and implementing HIV prevention programs.     

Structural approaches to HIV prevention

Recognition that social, economic, political, and environmental factors directly affect HIV risk and vulnerability has stimulated interest in structural approaches to HIV prevention. Progress in the use of structural approaches has been limited for several reasons: absence of a clear definition; lack of operational guidance; and limited data on the effectiveness of structural approaches to the reduction of HIV incidence. In this paper we build on evidence and experience to address these gaps. We begin by defining structural factors and approaches. We describe the available evidence on their effectiveness and discuss methodological challenges to the assessment of these often complex efforts to reduce HIV risk and vulnerability. We identify core principles for implementing this kind of work. We also provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.     

AIDS Knowledge and Risk Behaviors Among Alcoholic Adults

Fifty adults enrolled in an inner-city alcoholism clinic were interviewed to determine their knowledge about HIV/AIDS and transmission routes and to clarify their behavioral risk factors. Findings revealed that the sample had fairly good to excellent HIV/ AIDS knowledge. They possessed considerable misinformation about correct condom use, however, and knowledge levels were not correlated significantly with safer sexual practices. Men, younger women, and drinking clients engaged in more high risk sexual activities than did other respondents. The survey's findings have implications for AIDS prevention efforts with this population: (1) Assessment of differential HIV/AIDS risk factors should be incorporated routinely into alcoholism counseling; (2) interventions must be individualized to address specific risk factors and client beliefs; (3) specific skill development strategies that address negotiations in sexual encounters and which teach correct condom use should be added to AIDS information programs; and, (4) alcohol and other drug use must be linked explicitly to continued risk for HIV infection.     

Strengthening partnerships between Black Churches and HIV service providers in the United States

Across the United States, Black Churches play a significant role among the Black community and are increasingly being used to deliver Human Immunodeficiency Virus (HIV) prevention services. This study sought to investigate HIV service providers’ strategies for strengthening partnerships with churches to deliver HIV prevention services. Using a community-based participatory research approach, an HIV coalition and an academic institution formed a partnership to address the study aim. Individual interviews (n?=?16) were conducted with providers from medical institutions and HIV social support agencies. A thematic analysis focusing on recommendations for addressing the challenges and benefits of partnership with churches for HIV services was conducted. Participants’ interest in and intention to work with churches, as well as their comfort level discussing sexual health-related topics with religious congregations, was high. Four themes emerged to highlight the different perspectives of service providers’ recommendations for addressing challenges and strengthening partnerships with churches to deliver HIV services including: (1) carefully selecting churches and HIV services to provide, (2) gaining “buy-in” and support of church leadership, (3) taking advantage of conflict with church doctrine, and (4) choosing appropriate delivery strategies. Study findings demonstrate that although challenges exist, heath service providers in this region of the United States may be interested in addressing HIV among faith communities. Study findings also provide concrete solutions to previously documented barriers to HIV prevention in Black Churches. Such information will benefit researchers and practitioners seeking to expand effective HIV prevention efforts with Black Churches in communities who bear a disproportionate burden of HIV infections.     

Using the National HIV Behavioral Surveillance System to Inform HIV Prevention Efforts in the United States

The National HIV Behavioral Surveillance system (NHBS) was designed to monitor HIV prevalence and risk factors for infection among higher-risk individuals, i.e., sexually active men who have sex with men who attend venues, injection drug users who injected in the past 12 months, and heterosexuals living in low socioeconomic urban areas. These groups were selected as priorities for behavioral surveillance since they represent the major HIV transmission routes and the populations with the highest HIV burden. NHBS contributes to the nation’s program of HIV surveillance by being the only multi-site population-based system that provides estimates on key HIV prevention measures among high-risk HIV-negative individuals, HIV-positive individuals unaware of their infection, and HIV-positive individuals aware of their infection who are in and out of care. Accurate and precise data on the behaviors in these populations are critical for tracking the epidemic, planning effective responses, and monitoring and evaluating those responses. Reports in this supplement illustrate the uses of NHBS data at the national and local level and reflect ongoing efforts to improve the system and methods. As we look to the future, behavioral surveillance remains essential for characterizing and monitoring the burden of HIV infection and sexual and behavioral risks.     

The Effect of Motivational Interviewing-Based Counseling During Outpatient Provider Initiated HIV Testing on High-Risk Sexual Behavior in Rural Uganda

Provider-initiated HIV testing and counseling (PITC) has rapidly expanded in many countries including Uganda. However, because it provides HIV prevention information without individualized risk assessment and risk reduction counseling it may create missed opportunities for effective HIV prevention counseling. Our objective was to assess the effect of a brief motivational interviewing-based intervention during outpatient PITC in rural Uganda compared to Uganda’s standard-of-care PITC at reducing HIV transmission-relevant sexual risk behavior. We enrolled 333 (160 control, 173 intervention) participants in a historical control trial to test the intervention vs. standard-of-care. Participants received PITC and standard-of-care or the intervention counseling and we assessed sexual risk behavior at baseline and 3 and 6 months follow-up. The intervention condition showed 1.5–2.4 times greater decreases in high risk sexual behavior over time compared to standard-of-care (p = 0.015 and p = 0.004). These data suggest that motivational interviewing based counseling during PITC may be a promising intervention to reduce high-risk sexual behavior and potentially reduce risk of HIV infection.     

Choice in HIV testing: the acceptability and anticipated use of a self-administered at-home oral HIV test among South Africans

Combination HIV prevention is being widely promoted by funders. This strategy aims to offer HIV prevention choices that can be selected and combined to decrease HIV risk in ways that fit with each individual’s situation. Treatment as prevention and pre-exposure prophylaxis are two new evidence-based strategies to decrease HIV incidence, both of which require high HIV testing rates to be effective, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 90% of HIV-positive individuals knowing their status by 2030. However, HIV testing rates in many countries remain suboptimal. Just as no single HIV prevention method is ideal for all people in all situations, no single HIV testing modality is likely to be acceptable to everyone. By offering HIV testing choices, we may be able to increase testing rates. However, many low-resourced countries have been slow to take up new HIV testing options such as the self-administered at-home oral HIV test that is currently available in the United States. In this paper, we present findings from 20 in-depth interviews, conducted in 2010, documenting opinions about self-administered at-home oral HIV testing, a testing modality still largely unavailable in Africa. Participants were clients of three primary healthcare clinics in South Africa. Self-testing was seen as enabling confidentiality/privacy, saving time, and facilitating testing together with partners. However, concerns were raised about psychological distress when testing at home without a counsellor. Some suggested this concern could be minimised by having experienced clinic-based HIV testing and counselling before getting self-testing kits for home use. Thus, self-administered HIV testing could be an option added to the current testing modalities to address some important barriers to testing.     

Psychological and social correlates of HIV stigma among people living with HIV

Abstract

HIV/AIDS remains a highly stigmatized condition jeopardizing both prevention and treatment efforts. Prior research on the psychological and social correlates of HIV stigma has produced mixed results. This study examined whether demographic factors, mental health status, perceived health, mode of HIV transmission, social support, and risky sexual behavior were associated with perceived HIV stigma. Cross-sectional data collected from the intake questionnaires of clients receiving HIV-related social services at an urban clinic in the Southeastern U.S. were analyzed using multiple linear regression analysis. Results showed that younger age, heterosexuality, psychological distress, contracting HIV from sources other than injection drug use or homosexual contact between men, and not knowing your last sexual partner’s HIV status were positively associated with perceived HIV stigma. Implications of study findings for the design of HIV stigma reduction interventions are discussed.     

The role of behavioral research in HIV/AIDS prevention

Behavioral and social research has been at the core of HIV/AIDS prevention efforts, by identifying the factors that contribute to the risk of transmission and by developing effective behavioral interventions to modify that risk. The historical focus of behavior-change strategies on decision-making processes within the individual has evolved to include more attention to the dynamics of interpersonal relationships and the sociocultural contexts in which HIV-related risk behaviors occur.     

“I never thought that it would happen … ” Experiences of HIV seroconverters among HIV-discordant partnerships in a prospective HIV prevention study in Kenya

In spite of access to behavioral and biomedical HIV prevention strategies, HIV transmission occurs. For HIV-serodiscordant couples, prevention programs can be tailored to address individual and couples’ needs to preserve their relationship while minimizing HIV risk. Programs for serodiscordant couples may benefit from learning from experiences of couples who transmit HIV. We conducted 20 individual in-depth interviews with 10 initially HIV-serodiscordant couples who transmitted HIV during prospective follow-up at a peri-urban research site in Thika, Kenya. Data were analyzed inductively to identify situations that led to prevention failure and coping mechanisms. Inconsistent condom use driven by low HIV risk perception and alcohol use often preceded seroconversion while persistent blame frequently hindered couples’ communication soon after seroconversion. In this emerging era of antiretroviral-based HIV prevention, couples’ counseling can capitalize on opportunities to foster a supportive environment to discuss initiation and adherence to time-limited pre-exposure prophylaxis and lifelong antiretroviral therapy, in addition to strategies to reduce alcohol use, diffuse blame, and use condoms.